Cost-effective health care

There have been dramatic changes in the last decade affecting what can be achieved in the management of musculoskeletal conditions, but for various reasons these benefits are not reaching all those who could profit.
The current provision of care for musculoskeletal conditions reflects the past and current priorities given to these common but chronic and largely incurable conditions.The high prevalence of these conditions, many of which do not require complex procedures or techniques to treat effectively, and the lack of specialists means that most care is provided in the community by the primary care team.
This contrasts with the lack of expertise in the management of musculoskeletal conditions in primary care, since undergraduate education in orthopaedics and rheumatology is minimal in many courses and few doctors gain additional experience whilst in training for primary care. In addition there is little training in the principles of management of patients with chronic disease when understanding
and support are so important in the current absence of the effective interventions we would like to offer. The increased prevalence with age results in an attitude that these problems are inevitable. The consequence of these factors is that the patient all too often gets the impression that they should “put up and shut up”, “learn to live with it” because “it is to be expected” as part of their age. Although developing coping skills is an essential part of managing to live despite having a chronic disease, it is a positive approach and not one of dismissal. A greater understanding by all clinicians, particularly in primary care, of the impact of musculoskeletal conditions and how to manage them is essential to attain the outcomes which are currently achievable by best clinical practice.
Secondary care is largely based on the historical development of the relevant specialities rather than by planning. Orthopaedics has largely evolved from trauma services but has undergone dramatic developments in the past 40 years with the development of arthroplasties. Rheumatology has evolved from the backgrounds of
spa therapy and internal medicine. Physical therapy and rehabilitation has strong links with the armed forces. Manual medicine has developed to meet the demand of soft tissue musculoskeletal conditions and back pain. The growth of alternative and
complementary therapies reflects the failure of interventions to meetthe patient’s expectations and the large numbers with chronic musculoskeletal conditions seeking a more effective and better tolerated, more natural intervention. The development of pain clinics and services for helping people cope with chronic pain reflect ways
of trying to help people manage the predominant symptom of musculoskeletal conditions.
Secondary specialist care is within the hospital sector in the UK but predominantly outpatient based, and inpatient beds have often been in the smaller older hospitals that provided the subacute or rehabilitation services – caring more than curative interventions.
There has been a trend over several decades for these smaller units to close and services to be concentrated in larger district general hospitals where there is enormous competition for the ever reducing numbers of beds for inpatient care. Many rheumatologists now train with little experience of inpatient facilities and therefore, for example, have little experience of what can be achieved by
intensive rehabilitation alongside intensive drug therapy to control inflammatory joint disease. Lack of hospital facilities is now causing difficulties with the parenteral administration of newer biological therapies.
The management of musculoskeletal conditions is multidisciplinary but the integration of the different musculoskeletal specialities varies between centres. Usually rheumatologists or orthopaedic surgeons work closely with the therapists but there is little integration of the medical specialities themselves and there are few examples of clinical departments of musculoskeletal conditions embracing
orthopaedics, rheumatology, rehabilitation, physiotherapy and occupational therapy, supported by specialist nurses, orthotics, podiatry, dietetics and all the other relevant disciplines. Hopefully this will change with time as part of the integrated activites of the “Bone and Joint Decade”.
The outcome of musculoskeletal conditions has altered greatly. For many musculoskeletal conditions there are now effective strategies for prevention, treatments to control or reverse the disease processes and methods of rehabilitation to minimise impact and allow people to achieve their potential. This is detailed in subsequent chapters but some examples are given. Trauma can be prevented in many
circumstances such as road traffic accidents, land mines and in the workplace if the effective policies are implemented.The management of trauma can now result in far less long term disability if appropriate services are available in a timely and appropriate fashion. It is possible to identify those at risk of osteoporosis and target treatment to prevent fracture. Treatment can also prevent the progression of
osteoporosis even after the first fracture, with drugs which maintain or even increase bone strength. Structural changes can be prevented in rheumatoid arthritis by effective second line therapy with recognition of the need for early diagnosis and intervention.
Osteoarthritis cannot yet be prevented but large joint arthroplasty has dramatically altered the impact that it has on ageing individuals who would have lost their independence. There have been major developments in preventing back pain becoming chronic. There have been major advances in the management of pain. Pain control can
now be much more effectively achieved with new ranges of effective and well tolerated drugs, and there have been advances in techniques related to a greater understanding of the mechanisms of pain and its chronification.
There remain many outstanding problems concerning the management of musculoskeletal conditions. There are many interventions in use for which there is little evidence to prove effectiveness. Many of these are complex interventions dependent on
the therapist, such as physiotherapy, or provision of social support and these are complex to evaluate. Evidence is, however, essential to ensure such interventions, if truly effective, are adequately resourced in the future.
Many, however, are not benefiting from the proven advances and
achieving the potentially improved outcomes. This is largely because of lack of awareness, resources and priority. These resources are not just money to pay for new expensive drugs but also the human resources of clinicians and therapists with the necessary competencies to effectively manage those with musculoskeletal conditions. The public and many health professionals are not fully aware of what can now be achieved and therefore perpetuate a negative attitude. If they think little can be done, they do not seek expert help. Lack of awareness and knowledge of medical advances means that these are not delivered to the main benefactor – the patient. There are many suffering pain which could be much more effectively managed. Many
have impaired function inappropriately. Lack of knowledge of what can be achieved alongside a lack of awareness of the enormous burden on the individual and society leads to lack of priority and resources. There are few health policies that highlight the importance of musculoskeletal conditions despite their enormous costs to society and to the individual. As a consequence, for example, the waiting times for joint replacement surgery for osteoarthritis, a highly cost effective intervention, are amongst the longest in the UK.
The challenge is to ensure as many people as possible can benefit from the current effective means of prevention, treatment and rehabilitation.

Demand

The demand for care for musculoskeletal conditions is going to increase. The global disease burden of non-communicable disease was 36% in 1990 but it is predicted to be 57% in 2020. There are several reasons. First, because of the change in population
demographics. By 2030, 25% of the population in the UK will be over the age of 65 years and the prevalence of musculoskeletal conditions increases dramatically with age. Lifestyle changes that have happened in westernised countries are likely to increase musculoskeletal conditions, but most worryingly these lifestyle changes are also happening in the developing world along with inversion of the age pyramid which will result in the greatest predicted growth in chronic diseases. Lack of exercise will not only increase cardiovascular disease but exercise is also important in the prevention of osteoarthritis, maintaining bone mass and preventing falls. However, surveys in Sweden have shown that about 25–30% of middle aged men and 10–15% of middle aged women are completely inactive. It is also estimated that only 20% of the population who are 30 years and older are, from a health standpoint and when regarding physical conditions, sufficiently physically active.This means that almost 80% of the adult population in Sweden over the age of 30 is either not adequately
physically active or completely inactive. Other risk factors for musculoskeletal conditions that show similarly unfavourable trends are motorisation with subsequent accidents, obesity, smoking and excess alcohol.
Demand also relates to the expectation for health and this is increasing. At present many suffer in silence outside the healthcare system because they feel that little can be done for them. Many primary care doctors do not seek the latest interventions for their patients because of lack of awareness of what can be achieved. However, as there is increasing awareness of what is achievable, so there will be increasing demand. New technologies generate this demand and also contribute to the increased costs. In addition as the expectation of the right to good health related quality of life increases, then those in developing countries who, for example, are currently
suffering back pain silently will increasingly identify it as a health problem and expect medical intervention and social support.

Provision of health care

The way in which health care is provided can affect the level of care delivered and its outcome and this is the focus of current activity by WHO (World Health Organization). At present equal levels of care are not being delivered as there are countries of similar levels of income, education, industrial attainment and health expenditure with a wide variety of health outcomes. Some of this is due to differences in performance of the health systems. A health system includes all the
activities whose primary purpose is to promote, restore or maintain health and can therefore even include efforts to improve road safety where the primary intention is to reduce road traffic accidents (WHOWorld Health Report 2000). The health of the population should reflect the health of individuals throughout life and include both
premature mortality and non-fatal health outcomes as key components. A health system should also be responsive to the legitimate expectations of the population such as respecting their dignity, confidentiality and involving them in decisions. There should also be fairness in financial contribution so that households should
not become impoverished or pay an excessive share of income for healthcare and poor households should pay less than rich. Obviously the performance of any healthcare system can only be measured in relation to the resources available. The WHO World Health Report will now give information each year on the performance of health
systems of each country within this framework.
This failure of many health systems along with rising demands for health care, rising costs and limited resources is generating much debate about the most effective systems for the provision of health care. Economic and social development in all countries is increasingly taking a “market approach” and health can be viewed as another commodity. This must be balanced against the recognition that good
health is a prerequisite for human development and for maintaining
peace and security. It is also important that any system is equitable for all diseases whether acute and treatable or chronic disorders that require more care and support. Musculoskeletal conditions, as a major contributor to such non-fatal outcomes, need greater recognition of their importance and their specific needs must be considered to ensure appropriate systems of care.
There is a movement towards managing care so that the healthcare system provides cost-effective health care within the available resources. Managed care has developed in the USA where an organisation assumes responsibility for all necessary health care for an individual in exchange for fixed payment. Socialised healthcare
systems in the UK and Sweden are also systems that provide this form of care. This approach may not be the ideal for all countries but the tools of managed care may be of relevance.The three tools are first to be able to manage demand, secondly to have some control over management and finally to be able to influence care delivery so that it is cost effective. Demand can be controlled by making payments based on capitation not clinical activity, introducing gatekeepers to expensive secondary care, making some direct costs to the user and educating the public so that they are better able to care for themselves. Although some of these may be feared as barriers to professional and patient freedom of choice, making the person with the condition a more informed user of health care is in keeping with the principles of chronic disease management. Control over medical management is potentially more restrictive of clinical freedom but something many physicians are already used to where permission is required from the funder before certain interventions can be
performed. The use of evidence-based guidelines is also increasing and a principal of healthcare reforms in the UK. The important changes in the delivery of care are the increasing access of the public to advice through telemedicine and promoting self-care with greater use of non-doctors.This may be more appropriate to chronic diseases providing that it achieves the same outcome as more expert care, and
that this outcome is measured for all the goals of managing people with musculoskeletal conditions. These changes represent a reversal from “industrial age medicine” in which professional care dominates to “information age healthcare” in which professional care provides support to a system that emphasises self-care. Healthcare providers will progress from managing disease to promoting health. Lifetime plans for health promotion will be built on an intimate knowledge of
the person and their risk factors for various conditions. Within this context of changing systems of health care are the implications of how it will be delivered.What will be the resources in human capital as well as physical? What will be the political priorities? The settings for health care have changed over the centuries with the changes in what is expected and developments in what can be done.
Hospitals have played a dominant role in the provision of care, and they have evolved during the twentieth century from institutions that provide basic care and support to settings for medical treatment of increasing sophistication, effectiveness and cost. Advances in diagnosis have lead to the recognition of new, often treatable diseases. This has been paralleled by the massive expansion in
pharmaceuticals. There have been enormous changes in what can be achieved. Infectious diseases are becoming less common and interventions are meaning that many chronic incurable diseases are now becoming treatable and controllable, such as peptic ulcer disease, childhood leukaemias, some solid cancers, transplantation
and now the treatment of rheumatoid arthritis and osteoporosis.
There are now two competing roles for hospitals – highly technical procedure and “cure” based centres and, by contrast, centres that provide care which is usually multidisciplinary therapist based. The changes in systems of health care mean that such specialist facilities, although likely to remain a key part in the management of acute and chronic diseases, will increasingly be just one part of the
infrastructure to effectively prevent and treat musculoskeletal conditions. Provision of care closer to the person with the problem and more designed to help them manage their own health will need to be developed.The trends to develop skilled multidisciplinary teams that cross the various health sectors, to develop specialist nurses as key members of such teams as well as improving access to expert
information and advice using technology will meet many of these aims and reduce demands on specialist medical services. Specialised services will continue to have a major role in facilitating care, developing evidence-based strategies, undertaking research, providing education for the healthcare team as well as for those with
musculoskeletal conditions, and directly managing more complex cases. Their role is likely to become more strategic rather than just “hands on”.

Bones and joint futures. Anthony D. Woolf. BMJ Books